How to Hit the Mark With Documentation When Healthcare Policy Is a Moving Target

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By Maria St. Louis-Sanchez

In the past year, it's been tough to open a newspaper or watch TV without hearing about potential changes to the U.S. healthcare system or Medicare.

With the future healthcare landscape unclear, and the memory of Recovery Audit Contractor (RAC) audits that left some O&P practices facing recoupments from the Centers for Medicare & Medicaid Services (CMS) for high-end devices, many in the O&P profession worry about their future.

"I think there is still a kind of residual trauma [from the RAC audits], and there's still a concern that if I move forward and start to provide something that there's a chance…[CMS] will want their money back," says Michael Amrich, CPO, FAAOP, clinical education specialist for Liberating Technologies, a wholly-owned subsidiary of College Park Industries, headquartered in Warren, Michigan.

Unfortunately, traversing through this uncertain landscape is not going to get any easier for O&P professionals, says Kimberly Hanson, director of reimbursement, North America, Ottobock, headquartered in Austin, Texas.

"It is a very demanding environment," Hanson says. "Patients want to wear the right product for their lifestyle, and insurance companies don't want to pay for it. I believe reimbursement pressure will continue to rise and become more challenging than ever, and the belief is that insurance companies are focused on controlling costs, whether through denials, delays, or policy."

So, without control in Washington or influence over private insurers, what does an O&P facility have to do to stay in business? According to the experts: Have rock-solid documentation that hits the mark, despite changes in policy.

Potential Changes

Despite headlines and rhetoric from politicians, it's difficult to pin down specific changes to Medicare or the way that prosthetists and orthotists are being reimbursed. However, there is anecdotal evidence that some private insurers may be making it tougher to get prior approval.

"We know some O&Ps are experiencing automatic denials of prior authorization for all private insurance claims," says Dave McGill, JD, vice president of reimbursement and compliance, Össur Americas, Foothill Ranch, California. "This isn't based on any specific concern about the claim or the provider: It's 100 percent based on the payer taking a flat ‘no-pay' position on prior authorization for particular prosthetic devices."

Hanson says she has also seen insurers tightening their purse strings concerning what they will and won't reimburse. "We have seen an increase in insurance companies selling plans with very limited prosthetic benefits, if any at all, in order to keep premiums down for employers and self-insured beneficiaries," she says. "Unfortunately, it means that patients have less choice in what they can wear and fewer options to challenge the system because that is what their plan covers."

For cases like these, McGill says, it would help if O&P facilities shared information about what they are seeing so the industry can band together to fight the practice of blanket denials, he says.

"The best thing they can do is point out what's happening to groups like AOPA [the American Orthotic and Prosthetic Association] and NAAOP [the National Association for the Advancement of Orthotics and Prosthetics] …," McGill says. "This is the kind of issue that is hard to get fixed up front or at an individual facility level. At an industry level, we can do an outreach on a payer-by-payer basis."

For reimbursement issues that do not involve blanket denials, McGill says that the way facilities file claims and seek reimbursement has not changed despite the headlines. "From my perspective, it's still classic Claims 101," he says.

Overall, the experts say, O&P facilities should not be wary to submit claims for devices they know would be best for their clients.

"What happened with a lot of people was the fear of not getting reimbursed meant prosthetists started under-quoting patients," says Jonathan Cook, CPO, clinical education specialist, College Park. "There was a general trend in the industry to put K2 products on patients who could have possibly been K3 ambulators because [prosthetists] didn't want to run the risk of not being reimbursed."

That has equalized a bit over time, Cook says, but the fear of not being reimbursed is still on the minds of many in the industry. As the dust has settled from the RAC audits, O&P professionals are finding that reimbursements are easier to get than they were a couple of years ago. However, that may be because those same professionals are now much better, and more careful, with their documentation than they might have been in the past.

"A single misdated document can cost thousands of dollars in lost revenue," says Mitchell Dobson, CPO, FAAOP, vice president and compliance officer - patient care, Hanger, Austin, Texas. "The level of scrutiny continues to stay high and the level of diligence to meet it must also stay very high. More and more clinicians are finding themselves as policy experts, challenging erroneous denials, and fighting to keep their heads above water."

With the possibility of more changes on the horizon, O&P facilities need to ensure that their claims are as bulletproof as possible. The documentation should be strong enough for the claim to be approved the first time, and if it's not, everything needed for the appeal should be available. To make it happen, the experts say these steps are necessary:

1. Have documentation before delivering a device.

2. Include physician notes that validate the device that is being provided by the prosthetist or orthotist.

3. Be able to justify why a particular device is needed for the individual patient.

4. Set up checks and balances in the claims process to ensure that the billing office is following its own guidelines.

Get the Documentation First

Many O&P professionals think fondly about a time when they had more time for their patients and did not have to focus as much on documentation. That's just not the landscape any more, the experts say.

"Before the audits became common, clinicians spent more time with the patient than with the paperwork," Hanson says. "That has flipped. Correct documentation is key to the success of getting paid for the products and services they provide."

McGill acknowledges that getting exhaustive documentation before delivering a device can be time-consuming and frustrating, but says the alternative is worse. Submitting too many claims without proper documentation could backfire. "If you have claims get authorized that lack complete documentation and then those claims get audited later on, you will accidentally be sitting on a huge pile of dynamite," he says.

Instead, practices need to have everything lined up from the start to make sure their claim can withstand an audit.

"Doing it right the first time pays dividends," McGill says. "It paves a pathway to more claims getting approved or paid without delay. If the claim still gets denied, doing that work up front gives you everything you need on hand for a speedy appeal. You don't have to go chasing that information. You will already have everything you need to draft the appeal."

Hanson says practitioners should know in advance what they need to document in their notes and the information they need to capture during the visit. They should be clear in their notes and have a consistent method of evaluating and documenting patient care. To streamline the claims as much as possible, McGill recommends good practice management software that will provide the documentation from your office in real time. Practice notes should be specific to the patient and include exact activities the patient is restricted from, McGill says.

O&P documentation should be the easiest part of getting the necessary justification before delivery, McGill says. The harder part is getting the documentation needed from physicians and physical therapists to validate the claim. 

The experts differ about when it may be acceptable to risk delivery without final documentation from the physician.

Hanson says she would never recommend submitting a claim that is not going to be paid if audited.

"Clinicians should treat every chart as though it will be audited and create a structure in their offices to obtain the paperwork and review it prior to delivering the prosthesis to the patient," she says. Even if that means delays, it is best in the long run, Hanson says.

McGill says if the patient has an immediate need, and the prosthetist knows the physician and that he or she already understands everything an O&P facility requires for reimbursement, then it may be all right to take a chance and proceed to deliver the device before reviewing that physician's notes.

"You can proceed in that case because you know with a high degree of probability that the documentation will be solid," he says. "But if you're dealing with a doctor you haven't worked with before or doesn't know what's required, you may want to wait until you've actually received that supporting documentation before delivering an item, and that can take a while."

For situations like these, the experts recommend building strong relationships with physicians to help patients get care faster and ensure the O&P practice has everything it needs to get paid.

Getting Physicians to Work With You

The hardestpart of getting documentation is often the part that O&P facilities have the least control over—the notes they receive from physicians.

Having notes that validate the device selected for the patient is paramount for claim validation and to get it, O&P professionals should be good at working with physicians and talking to them about what is needed to ensure the patient is fitted as fast as possible. Unfortunately physicians are not always aware of the specific details they need to provide to get the best devices for their patients.

"A good alliance with a physician is essential," says Amrich. "It would behoove the prosthetist to educate the physicians about what they need and also newer technology the physician might not be aware of."

Cook says he has gone with patients to physician appointments, so they could all speak together and be on the same page. "I think it helps by getting the information firsthand and ensuring that the physician is aware that the reason you are obtaining this documentation is to make sure the patient is getting the best product possible."

Cook says notes from physicians should always include patient demographics including his or her height and weight, what activities the patient does daily, and what the physician sees as the patient's potential for ambulation.

"Obviously, getting this information can take time from a physician's day, but it's for the betterment of the patient and to provide the patient with a device that will improve their quality of life."

Sometimes educating physicians about O&P needs can go a bit too far, McGill says. Some O&P practices have provided pre-written templates for the physicians to sign that include a manufacturer or O&P practice logo, which can be a red flag for insurers.

"This coaching of the physician is looked down upon by Medicare and contradicts policy language," Dobson says. "In fact, the Medicare policy says that a form like that still has to be corroborated by the actual medical record, so you have essentially created work that does nothing to substantiate payment."

That said, McGill says, it is "completely appropriate" to provide physicians with guidelines about what information is necessary for the patient to receive a device. "It's okay to say to the doctor, ‘here's what I found; here's the information from you that Medicare requires be in your records to corroborate mine,'" McGill says. It can also help to provide a checklist or sheet that shows the type of information needed for the doctor to fill out in his or her normal format, he says.

Sometimes, he acknowledges, there is pushback from physicians. However, they too understand the need for documentation in their own practices and, ultimately, they also want what is best for the patient.

"Most doctors—when the rubber meets the road—recognize that when a patient needs their support and help, supporting their patient is the right thing to do."

Get the Best Justifications Possible

Good documentation doesn't stop with the physicians. Practitioners should also be able to justify their choice with evidence-based practices, the experts say. That means each device they choose should be proven to be effective for a patient with those specific needs.

"We think energy return in a prosthetic foot is a good thing, but we also need documentation with research backing that up, saying that energy expenditure may be reduced with this type of foot or that type of foot."

This kind of documentation may differ from what clinicians did in the past, Dobson says. "When documenting the necessity of a device before [the RAC audits], generally, clinicians used to focus on what the product or feature did, as compared to how it helps the patient," Dobson says. "The RAC audits, and other audits, have caused us to really assess the essential elements of a claim and the associated medical record."

This information is not always necessary for reimbursement, but it will be very helpful if there is a denial. With this information already available, the practitioner can prove why that specific device is necessary.

Cook cautions that clinicians should always work to find patient-specific devices and not just fit those that they are used to working with. It can be a red flag to insurers if a clinician always files claims for the same device.

Have Processes in Place

Knowing what should  be included in claims, and what is actually  included are often two different things, McGill says. Even if the practice staff knows what they are supposed to have, that knowledge does them no good if they don't have a system for ensuring that the information is always compiled.

McGill says that sometimes it is the practitioner who inadvertently prevents filing a good claim.

"The way most companies historically worked is the clinician had central control because the clinician was usually the business owner. And when a question arose between the clinical and billing departments, the business owner, representing the clinical side, always won," he says. "Then you would have a billing department first getting run over by the clinician and then getting screamed at because the claim didn't go through. The reason that happened is because the clinician did what was right for the patient but didn't check off all of the claim boxes before doing that."

To save their businesses from themselves, practitioners need to ensure that they have a system of checks and balances to ensure the claims process works as needed, the experts say. "I recommend all clinicians have their charts audited internally for the necessary documentation prior to submitting a claim," Hanson says. "The clinicians need to know what elements are missing and create new habits in their cadence of care to ensure they document the proper items."

Part of that process should also always include double checks, Dobson says.

"By internal double checks, I mean systems where the person who gathers or initially reviews the documents is not the one who provides a second look," Dobson says. "Often we will ‘see what we think we see' rather than what is there. Having a different person provide that double check is valuable. That is a form of monitoring that is essentially required of a good compliance plan. It is not enough to simply audit charts after the fact."

There will be times when a hard and fast claims process may need to be ignored for the sake of the patient, for example, in an urgent situation when a patient has to be fitted immediately and the office doesn't have the information in from the physician, McGill says.

"In a purely ideal world, you never fit a patient until you have corroborating information," he says. "But it's not he patient's fault. If the patient has an emergency need today, you may choose to proceed before knowing what the physician's notes will say."

In cases like those, practioners may make an exception, McGill says. But offices must remain diligent to ensure that the exception does not become the rule, or three months down the line, when the exception claims are audited and denied because of bad documentation, that practice could find itself in real trouble.

"The really important thing is to constantly monitor and understand when you are taking claim risks. If a single exception on a $25,000 claim balloons into ten exceptions, you may have unintentionally created a situation that could put you out of business if things go wrong. The key is to be aware of what you're doing at all times so that you can accurately balance business risk against patient benefit," says McGill.

Proceed as Usual

In truth, the experts say, there is not a lot that individual practitioners can do about the potential changes coming their way. The best they can do is to keep doing a great job serving their patients and keeping up with documentation.

"Submitting a claim without the appropriate documentation could put the provider at significant risk with not only the payer, but could lead to a governmental investigation," Dobson says. "It is important to remember that good documentation is part of good care."

Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com.